Self-perception of physical appearance of adolescents and associated factors in Addis Ababa, Ethiopia

Introduction Establishing a positive body image is a critical factor for adolescents’ physical and mental health, as it determines self-confidence, and sustainable individual growth and development throughout their lives. This reality needs to be supported by evidences generated locally. However, there is a lack of information in this regard in the study setting. Thus, the aim of this study was to assess the self-perception of one’s physical appearance and its associated factors among adolescents in Addis Ababa, Ethiopia. Methods and materials A community-based, cross-sectional study design was used to conduct the study. At the end of the multistage sampling procedure, a systematic random sampling technique was employed to select 308 study participants from selected districts. The questionnaire was adapted from previous studies as it was appropriate for local context. The data collectors were trained before the data collection and supervised during the data collection period, and the questionnaire was pretested. Bivariate logistic regression was used to identify candidate variables, and then variables with p<0.2 were taken to multiple logistic regressions to identify independent associated factors. Statistical significance was considered at P <0.05 with adjusted odds ratios calculated at 95% CIs. Result A total of 283 adolescents were participated in the study, with a response rate of 91.9%. The overall good self-perception of one’s physical appearance was 48.4% [95% CI = 43.8, 54.1]. Having a BMI between 18.5 kg/m2-24.9 kg/m2 (AOR = 2.56; 95% CI: 1.45, 4.54), presence of enough sport fields in the school (AOR = 1.89; 95% CI: 1.09, 3.29), having daily access to internet services (AOR = 1.69; 95% CI: 1.07, 2.94), following Ethiopian movies/cinemas (AOR = 2.46; 95% CI: 1.46, 4.15), and regularly following western movies/cinemas (AOR = 2.0; 95% CI: 1.11, 3.59) were significantly associated with a good self-perception of one’s physical appearance. Conclusion According to this study, only 48.4% of respondents reported a good self-perception of their physical appearance. Adolescents and their family need to work to bring normal body mass index, which in turn will increase good self-perceptions of their physical appearance. Schools and the local administrations need to increase availability and access to enough sport fields for students to strengthen their physical fitness, which increases their good self-perception of their physical appearance.


Introduction
Establishing a positive body image is a critical factor for adolescents' physical and mental health, as it determines self-confidence, sustainable individual growth and development throughout their lives. This reality needs to be supported by evidences generated locally. However, there is a lack of information in this regard in the study setting. Thus, the aim of study was to generate evidence by assessing self-perception of physical appearance and its associated factors among adolescents in Addis Ababa.
Methods and materials A community-based cross-sectional study design was used to conduct the study. At the end of the multistage sampling procedure, a systematic random sampling technique was employed to select 308 study participants from selected districts. The questionnaire was adapted from previous studies as it was appropriate for local context. The data collectors were trained before the data collection and supervised during the data collection period, and the questionnaire was pretested. Logistic regression was employed to identify the predictor variables. Statistical significance was considered at P <0.05 with adjusted odds ratios calculated at 95% CIs. Result The overall good self-perception of one's physical appearance was 48.4% [95% CI=48.8, 541]. Having BMI between 18.5 kg/m 2 -24.9 kg/m 2 (AOR=2.56; 95% CI: 1.45, 4.54), presence of enough sport fields in the school (AOR=1.89; 95% CI: 1.09, 3.29), having daily access to internet services (AOR=1.69; 95% CI: 1.07, 2.94), following Ethiopian movies/cinemas (AOR=2.46; 95% CI: 1.46, 4.15), and regularly following western movies/cinemas (AOR=2.0; 95% CI: 1.11, 3.59) were significantly associated with good self-perception of one's physical appearance. Conclusion According to this study, good self-perception of one's physical appearance was low. Adolescents and their family need to work to bring normal body weight and height, which in turn brings their normal body mass index, which in turn will increase good selfperceptions of their physical appearance. Schools and the local administrations need to increase access to enough sport fields for students to strengthen their physical fitness, which increases their good self-perception of their physical appearance.
Response: Comment Accepted. Merged accordingly. Comment 21: The researcher did not explained why BMI and MUAC measurement were used together? Study showed BMI and MUAC highly correlated in Adolescent. What was the assumptions behind using this two indices for nutritional assessment? Responses: The comment is right, different literatures showed that BMI and MUAC measurements are highly correlated. We assumed that the findings of our study may show the research communities another support in addition to available evidences if both measurements are done simultaneously. Besides, the assumption behind using these two indices for nutritional assessment among adolescents proving researchers thoughts such as "The MUAC is useful especially in monitoring severe under nutrition" and "The BMI is a commonly used measurement for screening both underweight and overweight". Comment 22: Were the researchers considering any assumptions for the appropriateness of the analysis they used? Why logistics regression analysis? Did the researcher check the assumption for it? Response: As our data is categorical data, we used logistics regression analysis which does not require linearity test. We have made same assumptions before starting the analysis. Example we have checked multi-collinearity test and our data is free from it. Comment 23: According to WHO BMI-for age (Obese: >2SD; Overweight: >1SD; Normal: 1 --2SD; Thinness: <− 2 SD; Severe thinness: <− 3 SD) and height-for-age below -2SD is used for stunting. The MUAC for age can also be used classified for adolescent age. The researcher did not clearly describe the BMI and MUAC classification in this regard. This needs to be clearly stated with the reference. This need to be clearly stated with the reference. Response: We included the BMI classification explanation with reference in the methodology part according to your comment. Please see sub section data collection tools and quality control under methodology part. Result section comments Comment 24: What was the base for monthly income classification? Responses: The classification of income is depend on the mean value of the income level taken as cut-off point. Comment 25: According to responses rated based on five Likert scales, namely, 1strongly disagree, 2-4 disagree, 3-not sure, 4-agree and 5-strongly agree, the overall mean perception of respondents 5 was 2.9 (±0.02). Based on the definition of good and low perception, approximately 157 (55.5%) 6 respondents had good perception, and 126 (44.6%) had low perception.
The above statement is not clear for reader Response: To make it more clear, we re-write it and add a table  The authors have declared that no competing interests exist. NO  General guidance is provided below.
Consult the submission guidelines for detailed instructions. Make sure that all information entered here is included in the Methods section of the manuscript.
Before conducting the study, ethical clearance was obtained from the Addis Ababa Health Bureau ethical clearance board and Addis Ababa educational bureau.
Participants' right to self-determination and autonomy was respected, and study participants were given any information they needed verbally and in written prior to self-administration. For those who were below 18 years old, consent from their parents was obtained. The rights of each respondent refusing to answer a few or all questions were respected. Participation was voluntary, and participants could withdraw from the study at any time without explanation Establishing a positive body image is a critical factor for adolescents' physical and mental 13 health, as it determines self-confidence, sustainable individual growth and development 14 throughout their lives. This reality needs to be supported by evidences generated locally.

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However, there is a lack of information in this regard in the study setting. Thus, the aim of study 16 was to generate evidence by assessing self-perception of physical appearance and its associated 17 factors among adolescents in Addis Ababa.

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A community-based cross-sectional study design was used to conduct the study. At the end of 20 the multistage sampling procedure, a systematic random sampling technique was employed to 21 select 308 study participants from selected districts. The questionnaire was adapted from 22 previous studies as it was appropriate for local context. The data collectors were trained before 23 the data collection and supervised during the data collection period, and the questionnaire was 24 pretested. Logistic regression was employed to identify the predictor variables. Statistical 25 significance was considered at P <0.05 with adjusted odds ratios calculated at 95% CIs.

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According to this study, good self-perception of one's physical appearance was low. Adolescents 35 and their family need to work to bring normal body weight and height, which in turn brings their 36 normal body mass index, which in turn will increase good self-perceptions of their physical 37 appearance. Schools and the local administrations need to increase access to enough sport fields 38 for students to strengthen their physical fitness, which increases their good self-perception of 39 their physical appearance.

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The problem of body image, self-perception and dissatisfaction with one's appearance is widely 45 discussed in the anthropological and medical literatures (1-4). Physical care and body image, 46 especially during adolescence, are social issues (5). Harter (1999) describes self-perception as to evaluative judgments of attributes within discrete domains such as physical appearance, 48 cognitive competence, athletic competence, social acceptance and so forth (6,7). Thus, self-49 perception develops through experience in social and physical environment, interactions with 50 significant others, and individual behavioral traits (8,9). As children develop a sense of 51 themselves, interact with the world, and gain experiences, their self-concept is affected. is 52 defined (10). 53 The physical changes that the body undergoes during adolescence have a profound impact on an 54 individual's personal and social identity (11). For this reason, the process of forming physical 55 self-perception can be considered inherent to this age and can also influence physical exercise 56 habits (5,12). From the above, it is possible to conclude that a good body image can be 57 associated with better self-perception, as well as a more active and less sedentary lifestyle (1).

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These interpretations are also influenced by significant others' evaluations, reinforcements, and 59 attributions of the individual's behavior (11,13).

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School is an important level of education in which adolescents continue to learn the minimum 61 level of knowledge and skills that every citizen should have (9,14). Entering to high school is a 62 transition to a new educational level and can be stressful for adolescents since they encounter a 63 new curriculum, possibly new and different friends, new teachers, preparation for an important 64 and life-changing exam, and entering puberty (14). Specifically, at the secondary level of education, adolescents acquire problem-solving skills and develop them according to social 66 values and basic skills for functioning in society(3). In addition, this educational process plays a 67 crucial role in the development of self-perception of their physical appearance in adolescents. 68 Studies have shown that the prevalence of body image dissatisfaction in developed countries 69 ranges from 35% to 81% in adolescent females and 16% to 55% in adolescent males (9,15-17).

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A community-based cross-sectional study design was used to conduct the study. The study was 99 conducted in Addis Ababa, Ethiopia. Addis Ababa is the capital city and largest city of Ethiopia 100 and also the country's political, economic, cultural and tourism center. It is located in the central  The source population of this study was all adolescents in Addis Ababa city who was attending 105 high school education. The study population was all adolescents in selected districts and 106 attending high school in selected sub cities. All selected adolescent students in selected districts 107 who were in high school education during the data collection time and in the adolescent age 108 group (10-19 years) were included in the study. Adolescents with chronic health problems, 109 especially those with diabetes, were excluded from the study.

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Sample size determination 111 The required sample size for this study was calculated by using a single population proportion 112 formula with the following assumptions: 95% confidence level, 5% margin of error and 19.5%  By considering 10% non-response rate, a total of 308 sample populations was included.

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Multistage sampling techniques were used to select study participants. First Kolfe Keranio and 119 Yeka sub city was selected from sub-cities in Addis Ababa using simple random sampling 120 system, then three districts from each selected sub cities was nominated using a simple random 121 sampling system. After the number of adolescent attending high school was identified in each 122 selected districts, the study population was assigned proportionally to each district as per the 123 number of adolescent students in high school in the district. Then, study participants were 124 selected by using a systematic random sampling techniques.

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 Dependent Variable: Self-perception of physical appearance. Good self-perception: -refers 127 to respondents who scored the mean and above the mean value of self-perception of one's 128 physical appearance score. Poor self-perception: -refers to respondents who scored below 129 the mean value of self-perception of one's physical appearance score. the questionnaire was pre-tested, then adjustment and correction was done based on the pretest 141 result. To ensure data quality, adequate training and orientation were given to data collectors and 142 supervisors. The completeness and appropriateness of the collected data were checked by 143 supervisors every day and corrected according to the identified problems. In addition, the 144 investigator monitored and evaluated the overall quality of the data collection process. Weight 145 was measured to the nearest 0.1 kg, and height was measured to the nearest 0.1 cm. According to 146 WHO the BMI-for age >2SD: Obese; >1SD: Overweight; 1 --2SD: Normal; <− 2 SD: Thinness; 147 <− 3 SD: Severe thinness and height-for-age below -2SD is used for stunting (21).

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Data analysis procedure 149 The data were entered into EPI data version 3.1 and then exported to SPSS version 23 for data 150 management and analysis. Descriptive statistics of frequency, percentage, means and standard 151 deviation were carried out. Logistic regression was employed to assess factors associated with 152 self-perception of one's physical appearance. Accordingly, independent variables with p<0.2 153 during bivariate logistic regression were included to multivariable logistic regression analysis to 154 determine the association between factors and good self-perception of one's physical appearance.

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Adjusted odds ratios with 95% confidence intervals and significance levels of P< 0.05 were used 156 identify the determinant of good self-perception of one's physical appearance.

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Ethics approval and consent to participate 158 Before conducting the study, ethical clearance was obtained from the Addis Ababa Health 159 Bureau ethical clearance board and Addis Ababa educational bureau. Participants' right to self-160 determination and autonomy was respected, and study participants were given any information 161 they needed verbally and in written prior to self-administration. For those who were below 18 162 years old, consent from their parents was obtained. The rights of each respondent refusing to 163 answer a few or all questions were respected. Participation was voluntary, and participants could 164 withdraw from the study at any time without explanation.

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Socio-demographic characteristics of respondents 167 A total of 283 adolescents participated in the study, with a response rate of 91.9%. About 168 144(50.9%) of respondents were male. The mean age of the respondents was 16.55 ± 1.2 (SD) 169 years. The majority of respondents 116(41%) were attending grade 9. More than 92% of 170 respondents had both parents (father and mother) alive. More than 70% monthly income level 171 were less than 18000 ETB (  the overall mean perception of respondents was 2.9 (±0.02). (Table 3).  (55.5%) respondents regularly followed Ethiopian and Western music's, respectively (Table 5). Level of self-perception of one's physical appearance 210 The overall good self-perception of one's physical appearance of respondents were 48.4% [95% covariates, BMI of respondents, availability of enough football fields in the school they are 220 learning in, daily access to internet service, following Ethiopian movies regularly, and following 221 Western music's regularly were significantly associated with adolescent self-perception of one's 222 physical appearance (Table 6). This study aimed to assess the level of self-perception of physical appearance and its associated body image dissatisfaction among adolescents in public school students (9). However, the 234 finding is higher than that of a study performed in Romania (22). The difference might be due to 235 differences in study settings in terms of development, culture and methodology used to assess 236 self-perception. Click here to access/download Supporting Information Self-perception of physical apperance base line data.sav the aim of this study was to assess the level ofgenerate evidence by assessing self-perception of 22 physical appearance and its associated factors among adolescents in Addis Ababa. implementedemployed to select 308 study participants from selected districts. The questionnaire 28 was adapted from previous studies as it was appropriate for local context. The data collectors were 29 trained before the data collection and supervised during the data collection period, and the 30 questionnaire was pretested. Logistic regression was employed to identify the predictor variables.

31
Statistical significance was considered at P <0.05 with adjusted odds ratios calculated at 95% CIs.

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Studies have shown that the prevalence of body image dissatisfaction in developed countries 105 ranges from 35% to 81% in adolescent females and 16% to 55% in adolescent males (9,15-17).

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Despite data-based evidence from developed countries, little is known about the prevalence of 107 adolescent body image and related factors of dissatisfaction in developing countries such as 108 Ethiopia (23).

Sample size and sampling strategydetermination
The required sample size for thethis study was calculated by using a single population proportion 160 formula with the following assumptions: 95% confidence level, 5% margin of error and 19.5%  By considering 10% non-response rate, a total of 308 sample populations was included.

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Sampling techniques 167 Multistage sampling techniques were used to select study participants. First Kolfe Keranio and 168 Yeka sub city was selected from subsidysub-cities in Addis Ababa using simple random sampling 169 system, then three districts from each selected sub citycities was selectednominated using a simple 170 random sampling system. TheAfter the number of adolescent attending high school was identified 171 in each selected districts, the study population was assigned proportionally to each selected district 172 as per the number of adolescent students in high school in eachthe district. Then, study participants 173 were selected by using a simplesystematic random sampling system.techniques.   To ensure data quality, adequate training and orientation were given to data collectors and    The data were entered into EPI data version 3.1, which is epidemiological software packages for   Table 1.. More than 92% of respondents had both parents (father and 253 mother) alive. More than 70% monthly income level were less than 18000 ETB (Table 1).

Self-perception of one's physical appearance
Good Self-perception Low Self-Perception to internet service, following Ethiopian movies regularly, and following Western moviesmusic's 320 regularly were significantly associated with adolescent self-perception of one's physical 321 appearance. See (Table 5.6).

Formatted
... school students(9). However, the finding is higher than that of a study performed in 341 Romania(20).However, the finding is higher than that of a study performed in Romania (22). The 342 difference might be due to differences in study settings in terms of development, culture and 343 methodology used to assess self-perception. strength, and decreased obesity (22,23). As such, the results of this study all support this reality.

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Those who reported that there was enough football field and physical activity in the school had a 360 highly good self-perception of their physical appearance. This result is consistent with a study 361 performed in Canada (22). Similarly, it is supported by a review paper focused on school-based 362 physical activity, body image, and academic performance.

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The findings of this study show that there is a positive relationship between using internet services 365 and self-perception of one's physical appearance. This means that compared to adolescents who 366 did not have access to the internet, those who had internet access had a highly good self-perception 367 of their physical appearance. In contrast to this study, many findings show that there is a negative Having access to a suitable sport field is very important for children's physical development.

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Physical fitness is related to the ability to perform physical activity and evaluate one's body image

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Similarly, it is supported by a review paper focused on school-based physical activity, body image, 396 and academic performance.

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The findings of this study show that there is a positive relationship between using internet services 398 and self-perception of one's physical appearance. This means, compared to adolescents who did 399 not have access to the internet, those who had internet access had a highly good self-perception of 400 their physical appearance. In contrast to this study, many findings show that there is a negative

Dear Editor,
Thank you for giving us the opportunity to submit a revised draft of our manuscript titled (Selfperception of physical appearance of adolescents and associated factors in Addis Ababa, Ethiopia) to Plos One journal. We appreciate you and the reviewer for your precious time in reviewing our paper and providing valuable suggestion. It was your valuable and insightful comments that led to possible improvements in the current version. The authors have carefully considered the comments and tried our best to address every one of them. We hope the manuscript after careful revisions meet your high standards. The authors welcome further constructive comments if any.
Below we have provide the point-by-point responses/clarification to editor and reviewer comments. In addition, all modifications in the manuscript have been highlighted in red in document uploaded named as "Revised Manuscript with Track Changes".

Comments from Editor:
Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response:
We had revised the manuscript as per PLOS ONE's style requirements including the file naming.
Comment 2: Statement related to financial disclosure.

Response:
The authors received no specific funding for this work. The same statement is included in the manuscript.
Comment 3: Issue related to data availability.

Response:
We have uploaded the underlying data as supporting Information files Comment 4: Your ethics statement should only appear in the Methods section of your manuscript.

Response:
The ethical statement is included under method section by removing from declaration part.
Comment 5: Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works, some of which you are an author.

Response:
We have made great effort to replace, Re-write and adjust those overlapping text.

Abstract section comments:
Response

Introduction section comments
Comment 5: It would be good to include a paragraph explaining how self-perception may be influenced by a variety of factors.
It is inconsistent throughout the document to use terms like 'dissatisfaction' and 'low self-perception'.

Responses:
We have included a paragraph explaining how varies factors do affect self-perception of physical appearance.
In relation to 'dissatisfaction' and 'low self-perception', some literatures use the first, other use the second one. Hence, in the introduction section part of this manuscript, there may be either of them or both because more of the introduction part was extracted from previous studies that might use either of them to explain all most the same issue. However, the finding of this study is depend on the operational definition we had provided in the methodology part which is either Good self-perception or Poor self-perception.

Comment 6:
The study was a community based cross sectional study. Why the study include only adolescent who attend high school education? Would not be easy to make institution (based) cross-sectional study if the participants are only adolescent who attend high school education?
Response: To make this point clear, this study was first planned to be done at institutional (school) level, however, due to covid-19, the schools were closed as part of covid-19 prevention protocol. Then we have changed to community based. So, the sampling unit is household not school.

Comment 7:
The researcher selects two sub-cities from Addis Ababa, Ethiopia from 10 or now is 11 sub-cities. Do you think that the result of the study generalizable to Addis Ababa?
Response: At the time of starting of this work, the sub cities in Addis Ababa were 10. Hence, we have selected only two sub cities due to limitation of available resources. However, as much as possible, we tried to make the sampling representative by using a simple random sampling technique to select the sub cities and districts.
Comment 8: I also highly recommend a thorough formatting of the paper for publication in the journal.

Response:
We have tried to format the paper according to the journal formatting style.

Comment 9:
The researcher did not mention how the two sub-cities selected? Was it randomly or purposively?
Response: The two sub cities was selected by simple random sampling system.
Comment 10: Is the sampling unit was household or school? This is not clear for the reader Response: The sampling unit was household. This study was first planned to be done at institutional (school) level, however, due to covid-19, the schools were closed as part of covid-19 prevention protocol. Then we have changed to community based. So, the sampling unit is household not school.
Comment 11: How many household or school was included in the study?
Response: 308 households was included.
Comment 12: It is also not clear how simple random sampling was applied at community based cross-sectional study or was it school based

Response:
The comment is well taken. It is typing error. Corrected to Systematic random sampling system.

Comment 13:
The sample size calculation not clearly described. What was the proportion of 19.5%? Was it dissatisfaction on self-perception? Why the researcher uses the proportion 50% which can give the maximum sample size for the cross-sectional study. The researcher also did not describe the adjustment of sample size because of multistage sampling strategy.
Response. Corrected and we had included sample size calculation description. 19.5% is the proportion of satisfaction not dissatisfaction. As you know 50% is recommended if there is no any previous study done on the topic. Thus why we used the available reference.
Comment 13: Dependent Variable: Level of self-perception of physical appearance: bring the operational definition here.

Response:
We had already included operational definition in methodology part. However, as per your comment we have merged with dependent variable.

Comment 14:
The researcher is not consistently used terms in relation to self-perception. In the introduction section they used terms 'dissatisfaction' and in the method they used 'good-self-perception' and 'low-self-perception'.
Response: In relation to 'dissatisfaction' and 'low self-perception', some literatures use the first, other use the second one. Hence, in the introduction section part of this manuscript, there may be either of them or both because more of the introduction part was extracted from previous studies that might use either of them to explain all most the same issue. However, the finding of this study is depend on the operational definition we had provided in operational definition in the methodology part which is either Good self-perception or Poor self-perception.
Comment 15: Why the researcher wants to use the mean score to classify the self-perception as mean can be affected by skewness. Did the researcher checked the normal distribution of the data before they decide to use the mean score classification?
Responses: We used mean as cut-point, because our data is normally distributed data.

Comment 16:
The classification term also makes confuse the reader, for example, in the abstract section the researchers said, "Good perception of one's physical appearance was low". This makes confused with the self-perception classification ''Good" and "low". I would suggest "good" and "poor' or "high" and "low" or "satisfied" and "dissatisfied" Responses: It good and appropriate comment, so, as per your comment we corrected the operational definition as high" and "poor" satisfaction. As such, this operational definition was used to describe the satisfaction level of the finding of the study. Merge these two statements into one Response: Comment Accepted. Merged accordingly.

Comment 21:
The researcher did not explained why BMI and MUAC measurement were used together? Study showed BMI and MUAC highly correlated in Adolescent. What was the assumptions behind using this two indices for nutritional assessment?
Responses: The comment is right, different literatures showed that BMI and MUAC measurements are highly correlated. We assumed that the findings of our study may show the research communities another support in addition to available evidences if both measurements are done simultaneously. Besides, the assumption behind using these two indices for nutritional assessment among adolescents proving researchers thoughts such as "The MUAC is useful especially in monitoring severe under nutrition" and "The BMI is a commonly used measurement for screening both underweight and overweight".

Comment 22:
Were the researchers considering any assumptions for the appropriateness of the analysis they used? Why logistics regression analysis? Did the researcher check the assumption for it?
Response: As our data is categorical data, we used logistics regression analysis which does not require linearity test. We have made same assumptions before starting the analysis.
Example we have checked multi-collinearity test and our data is free from it.
Comment 23: According to WHO BMI-for age (Obese: >2SD; Overweight: >1SD; Normal: 1 --2SD; Thinness: <− 2 SD; Severe thinness: <− 3 SD) and height-for-age below -2SD is used for stunting. The MUAC for age can also be used classified for adolescent age. The researcher did not clearly describe the BMI and MUAC classification in this regard. This needs to be clearly stated with the reference. This need to be clearly stated with the reference.

Response:
We included the BMI classification explanation with reference in the methodology part according to your comment. Please see sub section data collection tools and quality control under methodology part.

Result section comments
Comment 24: What was the base for monthly income classification?

Responses:
The classification of income is depend on the mean value of the income level taken as cut-off point.
The above statement is not clear for reader Response: To make it more clear, we re-write it and add a table